Form Member Director Fo Member Director Fo Federal Home Loan Bank Member Director Eligibility Certi

FEDERAL HOME LOAN BANK MEMBER DIRECTOR ELIGIBILITY CERTIFICATION FORM (REVISED)
INSTRUCTIONS
This Federal Home Loan Bank Member Director Eligibility Certification Form must be completed by
individuals wishing to accept a nomination to stand for election as a member director of the Federal
Home Loan Bank of [TO BE COMPLETED BY EACH BANK] (Bank) or to be considered for appointment by
the Bank’s board to fill a member directorship that has become vacant. It must also be completed
annually by each incumbent member director. Your responses to the questions on this Form will assist
the Bank in verifying that you meet the eligibility requirements to serve as a member director.
You are eligible to serve as a member director of the Bank only if you meet all of the following
requirements:
•

You are a citizen of the United States;

•

You are an officer or director of a member institution of the Bank:
o That was a member of the Bank as of December 31, [PRIOR YEAR]; and
o Whose voting state for purposes of Bank directorship elections is the state that is
represented by the directorship for which you have been nominated; and

•

Each member of the Bank for which you are an officer or director is in compliance with all of its
applicable minimum capital requirements established by its primary regulator (this requirement
does not apply in the case of any member for which you are an officer or director that does not
have capital requirements established by a primary regulator, such as a non-depository
community development financial institution).

These eligibility requirements may be found in sections 7(a) and (b) of the Federal Home Loan Bank Act,
12 U.S.C. 1427(a) and (b), and sections 1261.5(a) and (b) of the regulations of the Federal Housing
Finance Agency, 12 CFR 1261.5(a) and (b).
Please follow the instructions below appropriate for the purpose for which you are completing this
Form.
NOMINEES IN THE ANNUAL ELECTION CYCLE
If you have been nominated to stand for election as a member director of the Bank you must complete
and execute this Form and submit it to the Bank on or before the date specified by the Bank to accept
the nomination. If you do not submit a completed and executed Form by that date, you will be deemed
to have declined the nomination. By law, the Bank may not permit a directorship nominee to stand for
election unless it has verified that the nominee is legally eligible to serve in the directorship for which he
or she has been nominated. Further, the Bank may neither declare elected any nominee nor seat any
director-elect whom it has reason to know is ineligible to serve.
CANDIDATES TO FILL A VACANT MEMBER DIRECTORSHIP
If the Bank’s board of directors is considering you as a candidate to fill the unexpired term of office of a
vacant member directorship on the Bank’s board, you must complete and execute this Form and return
it to the Bank on or before the date specified by the Bank. If you fail to submit a completed and
executed Form by that date, or if you submit a Form that does not adequately demonstrate that you
meet all applicable eligibility requirements, the Bank may determine that you are ineligible to serve, in
which case the Bank’s board would be prohibited by law from electing you to fill the vacant directorship.
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FEDERAL HOME LOAN BANK MEMBER DIRECTOR ELIGIBILITY CERTIFICATION FORM (REVISED)
By law, the Bank’s board may not elect any person to fill a vacant directorship unless it has verified that
the individual is legally eligible to serve in that directorship.
ANNUAL ELIGIBILITY CERTIFICATIONS BY INCUMBENT DIRECTORS
The Bank is required by law to solicit information from its incumbent directors annually to verify that
each director remains in compliance with the applicable statutory and regulatory eligibility
requirements. During each calendar year that you are an incumbent member director, you must
complete and execute this Form and return it to the Bank on or before the date specified by the Bank. If
you fail to submit a completed and executed Form by that date, or if you submit a Form that does not
adequately demonstrate that you continue to meet all applicable eligibility requirements, the Bank may
determine that you are ineligible to serve, in which case it would be required by law to declare your
directorship vacant.
YOUR PERSONAL INFORMATION
Please provide your personal information as indicated in Questions 1 – 3.
1. Full Name:
2. Other Names Currently or Formerly Used, or Known by:
3. Contact Information:
•
•
•

Phone number (leave room for multiple; indicate home, office, or cell):
E-mail address:
Mailing address: Number/Street (or PO Box), City, State, Zip Code

ELIGIBILITY REQUIREMENTS
Please answer in full Questions 4 – 6, which pertain to your compliance with the statutory and
regulatory eligibility requirements for member directors. You may continue your answers onto
additional pages, if necessary, each of which shall be attached to, and deemed a part of, this Form.
4. Citizenship. Are you a citizen of the United States? ___ Yes ___ No
5. Primary Member Affiliation. Please provide the following information about the entity you
serve as an officer or director that is a member of the Bank on whose board you serve or have
been nominated to serve:
•

Name of the member:

•

FHFA ID number of the member:

•

Voting state in which the member is located:

•

Your title or position:

•

Your business address at the member:

•

Does this member comply with all applicable minimum capital requirements established
by its primary regulator? ___ Yes ___ No ___ Not Applicable

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FEDERAL HOME LOAN BANK MEMBER DIRECTOR ELIGIBILITY CERTIFICATION FORM (REVISED)
6. Other Member Affiliations. Please provide the following information about any other entity
you serve as an officer or director that is a member of the Bank on whose board you serve or
have been nominated to serve (if more than one, please provide the information on a separate
sheet, which shall be deemed a part of this Form):
A. Other than the member you listed in response to Question 5, do you serve as an officer
or director of any other institution that is a member of this Bank? ___ Yes ___ No
B. If you answered Yes to Question 6A, please provide the following information for each
member of the Federal Home Loan Bank that you serve as an officer or director:
o Name of the member:
o FHFA ID number of the member:
o Your title or position:
o Does this member comply with all applicable minimum capital requirements
established by its primary regulator?
___ Yes ___ No ___ Not Applicable
By executing this Form, you are certifying that the information you have provided is true, correct, and
complete to the best of your knowledge and that you understand that you have a continuing
obligation to inform the Bank of any facts that may call into question your eligibility or ability to serve
as a Bank director. You further acknowledge that the Bank and the Federal Housing Finance Agency
may perform a background check on you, including without limitation regarding any information
disclosed herein.
Signature:

Dated:

Privacy Act Statement: In accordance with the Privacy Act (5 U.S.C. 552a), the following notice is
provided. This information is solicited under authority of 12 U.S.C. 1427(a) and (b) and 12 CFR 1261.5,
1261.7, and 1261.10 to 1261.13. Furnishing the information on this Form is voluntary, but failure to do
so may result in your not meeting the statutory and regulatory eligibility requirements to serve as a
Federal Home Loan Bank member director. The purpose of this information is to facilitate the timely
determination of your eligibility to serve as a member director. Information may be disclosed in
accordance with the routine uses identified in FHFA-System of Records Notice FHFA-8 Federal Home
Loan Bank Directors, which may be found at
https://www.fhfa.gov/AboutUs/FOIAPrivacy/Documents/SORNs/FHFA8%20Federal%20Home%20Loan%20Bank%20Directors.pdf.
Paperwork Reduction Act Statement: Notwithstanding any other provision of the law, no person is
required to respond to, nor shall any person be subject to a penalty for failure to comply with, a
collection of information subject to the requirements of the Paperwork Reduction Act, unless that
collection of information displays a currently valid OMB Control Number.
OMB No. 2590-0006
Expires ##/##/20##

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